de la Porte Pieta W F Bruggink-André, Lok Dirk J A, van Veldhuisen Dirk J, van Wijngaarden Jan, Cornel Jan H, Zuithoff Nicolaas P A, Badings Erik, Hoes Arno W
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Heart. 2007 Jul;93(7):819-25. doi: 10.1136/hrt.2006.095810. Epub 2006 Oct 25.
To determine whether an intensive intervention at a heart failure (HF) clinic by a combination of a clinician and a cardiovascular nurse, both trained in HF, reduces the incidence of hospitalisation for worsening HF and/or all-cause mortality (primary end point) and improves functional status (including left ventricular ejection fraction, New York Heart Association (NYHA) class and quality of life) in patients with NYHA class III or IV.
Two regional teaching hospitals in The Netherlands.
240 patients were randomly allocated to the 1-year intervention (n = 118) or usual care (n = 122). The intervention consisted of 9 scheduled patient contacts-at day 3 by telephone, and at weeks 1, 3, 5, 7 and at months 3, 6, 9 and 12 by a visit-to a combined, intensive physician-and-nurse-directed HF outpatient clinic, starting within a week after hospital discharge from the hospital or referral from the outpatient clinic. Verbal and written comprehensive education, optimisation of treatment, easy access to the clinic, recommendations for exercise and rest, and advice for symptom monitoring and self-care were provided. Usual care included outpatient visits initialized by individual cardiologists in the cardiology departments involved and applying the guidelines of the European Society of Cardiology.
During the 12-month study period, the number of admissions for worsening HF and/or all-cause deaths in the intervention group was lower than in the control group (23 vs 47; relative risk (RR) 0.49; 95% confidence interval (CI) 0.30 to 0.81; p = 0.001). There was an improvement in left ventricular ejection fraction (LVEF) in the intervention group (plus 2.6%) compared with the usual care group (minus 3.1%; p = 0.004). Patients in the intervention group were hospitalised for a total of 359 days compared with 644 days for those in the usual care group. Beneficial effects were also observed on NYHA classification, prescription of spironolactone, maximally reached dose of beta-blockers, quality of life, self-care behaviour and healthcare costs.
A heart failure clinic involving an intensive intervention by both a clinician and a cardiovascular nurse substantially reduces hospitalisations for worsening HF and/or all-cause mortality and improves functional status, while decreasing healthcare costs, even in a country with a primary-care-based healthcare system.
确定由一名经过心力衰竭培训的临床医生和一名心血管护士在心力衰竭（HF）诊所进行的强化干预，是否能降低NYHA III或IV级患者因HF恶化导致的住院率和/或全因死亡率（主要终点），并改善其功能状态（包括左心室射血分数、纽约心脏协会（NYHA）分级和生活质量）。
荷兰的两家地区教学医院。
240名患者被随机分配至1年的干预组（n = 118）或常规治疗组（n = 122）。干预措施包括9次预定的患者接触——出院后一周内或门诊转诊后，第3天通过电话，第1、3、5、7周以及第3、6、9、12个月通过门诊就诊，由医生和护士联合进行强化指导的HF门诊。提供口头和书面的综合教育、优化治疗、便捷的门诊服务、运动和休息建议以及症状监测和自我护理建议。常规治疗包括由相关心脏病学部门的个体心脏病专家发起的门诊就诊，并遵循欧洲心脏病学会的指南。
在12个月的研究期间，干预组因HF恶化导致的住院次数和/或全因死亡人数低于对照组（23例对47例；相对风险（RR）0.49；95%置信区间（CI）0.30至0.81；p = 0.001）。与常规治疗组（降低3.1%；p = 0.004）相比，干预组的左心室射血分数（LVEF）有所改善（提高2.6%）。干预组患者的总住院天数为359天，而常规治疗组为644天。在NYHA分级、螺内酯处方、β受体阻滞剂最大剂量、生活质量、自我护理行为和医疗费用方面也观察到了有益效果。
即使在一个以初级保健为基础的医疗体系国家，由临床医生和心血管护士共同进行强化干预的心力衰竭诊所，也能显著降低因HF恶化导致的住院率和/或全因死亡率，改善功能状态，同时降低医疗费用。
